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Thursday, June 30, 2011

Guest post: No more second guesses

I walked in and out of his room repeatedly during my 30 hour shift, he was the one I was worried about. It was the same room where, on my first ICU shift, my patient had died in an early morning code. I feared that the same would happen to this patient, however I did not hope to avoid death of this patient, just delay it enough so that his family could arrive. The patient was a young man dying of metastatic cancer. I knew that I had to get him through to the early morning so that his family could be there by his side. So armed with my lasix and morphine and one of the best nurses I have worked with, we both made it through the night. I was as happy as I could be in the face of death, to see his family walk through the door. We finished rounds, I finished my notes, and headed home. I knew it wouldn’t be long. I later found out that the patient died about half an hour after I left, with his mother and father holding his hands, just about the same time I was arriving home to eager hugs from my own two boys.

I hadn’t allowed myself to think about my kids all night, I had forced them out of my consciousness, so that I could do my job. I did this to protect myself from imagining what I would do if it were one of my sons in that bed. I drew the line between hospital and home, and I stuck to it, for better or worse. At the start of internship I thought I would call home each night I was on call to tell my kids goodnight. I never did this, in fact, most nights I didn’t have time to sit for dinner, aside from bites while writing notes into the wee hours of the morning. What bothered me most, perhaps, was that I didn’t even think about doing it most nights. I can’t count the number of bedtimes I missed or the number of daycare pickups my husband had to do this year. It is acceptable to me to have to miss a soccer game or a play, it is not acceptable to me to miss most soccer games or most plays. I can deal with missing a bedtime or a daycare pickup, but I do not want this to be the norm and I certainly never want to reach the point where I feel that it is acceptable.

I wrote just over a year ago about my mixed emotions on my match and my future career in dermatology. I felt logically, at the time, that this was the correct choice for me and my family, I just wasn’t sure emotionally. Now, days from finishing my internship, I am thankful that I made the logical, not the emotional decision. What a year it has been. In my professional life, I have performed my first deliveries and pronounced my first deaths, I have treated infants and I have treated senior citizens, I have stayed awake for a 30 hour shift and returned home to stay awake with my children for several more hours, I have made tough decisions and I have made mistakes. In my personal life, I have uprooted my family and exposed my husband to more call nights than I can count. I have come to appreciate his patience and commitment to our family in a way I never knew that I could. And, I have found clarity in my decision to pursue dermatology. I think it truly hit me that dermatology, had in fact, been the right choice on my ER rotation this year. I was never as happy as when I was able to fill my day with patients with chief complaints of rash and lac repair. Or perhaps it was when I reported skin findings while on the cardiology service on a patient admitted for a STEMI. Or when I noticed all I was teaching my medical students were skin findings and that I actually liked to look at the NEJM photo quizzes of skin findings for amusement. Perhaps some of my doubts from a year ago were unfounded. I am now to the point where, had I to make the choice again today, I could do it with much less angst, knowing that I will enjoy my work and that I will have a tolerable lifestyle.

After this year, I know that I could have been successful in either ob/gyn or peds and I would have been satisfied with my work life. In fact, in both of these rotations, attendings approached me about why I hadn’t gone into that field. I give the one liner to these attendings and anyone else who asks, which goes a little something like this: “I love that in dermatology I will get to do both medicine and small surgeries, that I can follow patients across the lifespan, that I can cure cancer in 20 minutes, and that I can be home with my kids at night.” But the longer answer is that I know myself enough to know that I do not do things half heartedly. I am there when I need to be, until everything is finished and when I am at work, my mind is completely there.

I need a career where I don’t have to feel guilty about how much I work or that I enjoy my work so much that I am not thinking about my kids and husband throughout most of the day. And I need a career where I don’t go home and feel strange that I can be so emotionally distant from the things I have seen that day. In dermatology I can have all of these things. I love so many aspects of medicine and I feel privileged to have been a part of births and deaths and to have had patients share with me the most intimate details of their lives on a daily basis. I will have patients who are as thankful to me for enabling them to control their acne or psoriasis as they would have been had I been there for the delivery of their children. I will not have to tell another woman that she is miscarrying or tell another wife that her husband has died on my watch. I am frightened as I move forward, for the sheer mass of information I will have to master, but relieved that I will be able to study at home at night, after putting the kids to sleep, where I cannot forget or ignore my life beyond the walls of the hospital.

I know I'm going to sound like a bitch saying this, but I have to get it off my chest:

This post irks me, as did your last one, and it's hard for me to articulate why. I guess it's because derm is so horribly competitive and here you were, complaining about your match. It's sort of like if you were complaining about having too much money, and then you finally posted saying that you were OK with having too much money, that you've reluctantly decided it's a good thing for you.

It's not like the rest of us are OK with how many soccer games and plays we miss. You're really fortunate that you liked and were able to match in a field that allows you that kind of flexibility and still pays very well. You act like being in derm is such a hardship. The people in my class who wanted to match in derm would have happily stepped on my face to get a spot, so this is just.... irritating.

Wow, Marie. Can you say CRABBY? Maybe you ought to stop reading KC's posts and get a little more sleep.

KC, a fine post (IMO). Thanks for sharing. It's hard, no matter who you are or what profession you're in not to miss your kids. It's not just doctors who work super duper hard and long hours. A good friend of mine leaves every Monday morning, and is not back home until Friday evening for her work. So yes, lots of people miss those special times. But, it's still OK to complain about it! And we're here to be supportive (well, I guess I am) when you do need to complain.

Kudos, Marie for speaking out your mind. I guess it has to do with new generation (are they generation X or Y) that has so much entitilement and self-pity and has to be praised for every little things they do. Above post is very confusing, hard to understand what author is trying to get across. Many (all) of us have worked 30h, have kids and miss our families. But we make it a go, adjusting hours/exepctations here and there. Personally I am very happy in IM, job 8 to 5, no overtime, raising kids. My 2 friends are misirable in dermatology 11-12 hour days, charting away at nights. I would hope this author make more valid and clear points in next post.

I love this post (didnt read the first post) we all need to be sure that the path we take in medicine leads us to joy and satisfaction and I think that is what this post was about...derm is competitive but you couldn't pay me a million bucks to do it (even if I was offered the position )...or radiology or ophthalmology. I love cardiology and despite my ridiculous schedule and time away from family that is my niche in life. KC has found hers and is happy, hope we all can be happy too.

@ Marie- I wasn't trying to whine/complain about my match, rather trying to explore the reasons why I made that decision. Immediately after matching I wondered if I had chosen for the wrong reasons, but after the experiences of this year, I am satisfied with my choices. Thankfully, I was in place where I could make that decision and I am sorry for your friend that she was not. Just because the field of dermatology is competitive, does not mean that it is for everyone, I know there are those who look at dermatology and find it just about the worst thing they could imagine to do in medicine. I never tried to say derm was a hardship, just that by there are so many parts of medicine I enjoy, it's hard to give some of them up to focus on one area, while, at the same time I know I personally might not be the best generalist.

We all place different values on different aspects of our lives. I know no one likes to leave their kids or miss soccer games, but we all make choices as to what we can live with and what we will regret. The experiences I have had this year were in no way unique to anyone in medicine. I know we all go through long shifts and the challenges of internship. I am not trying to complain nor boast about the things that I have done, they are common to those of us in medicine and pale in comparison to the requirements placed on those who went through residency before work hour restrictions. These experiences are, however, the experiences that have validated my decisions.

I guess the point of my writing was that chosing a specialty can be a difficult decision and one often cannot know if it was the correct decision until she has lived it.

I appreciated this post. I'm in a very different position - already in what could be a very family-friendly specialty, but trying to combine it with a decidedly not family-friendly major research career, and wondering if I should just scale back to clinical work alone - that nonetheless has very similar themes and issues.

@Marie: Your comments are interesting to think about, as well. It strikes me that many of the things you're talking about - the resentment that someone can have so many options that actually many others covet or aren't even in a position to begin hoping for, and yet be agonizing about the difficulties of that life despite its privileges - are actually the same core complaints lodged against anyone who agonizes about work/life balance while in medicine at all. And, understandably. I have many of the same feelings directed towards myself sometimes - for example, when I complain about how underpaid I feel that after 4 years of medical school, 4 years of PhD, and the first 5 years of residency/fellowship I'll still be making 5X,000/y - which in a very high cost of living city isn't enough to rent, childcare, retirement savings and groceries in the same month. And then I visit with my childhood friend raising her son as a single mother working part time minimum wage jobs where she can get them, and I feel like a total jerk. And THEN I get an email from one of my cousins in the third world, who is ecstatic that she finally has a job that will pay her family enough to start to build some savings and cover a better school for her kid - and all she has to do is live 4 hours away from them by bus during the week. And I REALLY feel like a jerk.

But - that doesn't change the actual day to day sense of loss I have at how little I see my own child, or my agony about how to weigh my family's immediate needs vs the very real good I hope to bring to society by continuing my research. Yes, I know it's an incredibly privileged position to be in. But yes, I still agonize about how to make the best decisions given the luxuries (and difficulties) that make up my life. That's what we all do, every day.

And I'm glad places like this blog are around to help us have a place to discuss these issues with others who are able to react with understanding and empathy, rather than just the true but not always so useful reminds that we're lucky to be in these binds to begin with.

This post rubbed me the wrong way too and I'm trying to figure out why. I think it may be the fact that you're writing about derm, as other people have alluded to in their comments. I think it might also be a bit of the holier-than-thou tone where you talk about your values.... Not sure though. Will have to think about it.

To Anon: I agree, people complaining about life as a doctor (or in med school) is undoubtedly really irritating to other people who desperately want to be doctors.

Maybe there's no real difference between this post and those posts. But I guess what irked me is this: a large percentage of people who go into derm do it for lifestyle (don't say it isn't true!). Whereas I think people who go into medicine do it for various reasons, many of which are altruistic (or more likely to be). So I feel more sympathy for someone whose intentions were probably noble, rather than someone making a decision for lifestyle and money and then expecting everyone to feel sympathy for them.

Again, I'm sure this sounds terribly bitchy or cranky or whatever, and if so, it's probably due to my extremely negative experiences with everyone I knew who matched in derm. None of them had the slightest interest in skin, that's for sure. I don't think I would have made a comment like this about a future radiologist, but there's just something super competitive about derm. (To the OP: I'm not at all saying you're like that, but it's amazing how all the worst gunners in my class gravitated to derm.)

Sorry, I just wanted to express my opinion. As I said, I'm happy for you that you're pleased with your career choice.

This post does rub the wrong way, and like another anon said not sure why. When Fizzy writes about her doubts, it is human and understandable(been there, done that), but this post sounds like princess complaining about life in a royal palace. This post's writer wrote a year ago about her agonizing pain of having to choose derm for life style (most people advised she choose another specialty if derm is such a painful choice, but it was not why she wrote the post, she still chose derm). Now she writes Thank God she THINKS she can like derm enough to be "satisfied". I cannot sympathize with this writer, she is self-indulgent in her thought process. But...I can cry over posts written by Cutter, RH+, GCS15 et al. Thanks, group, for great entries. Sorry to see many people did not catch the subtle falvor of the post

OK, in all this talk about whining and slef indulgence - let's turn this argument around a bit: Because someone is smart, or has had breaks that someone else didn't have, or worked really hard and now has choices...this makes that person in some way LESS worthy and therefore not ALLOWED to have second thoughts about a decision?I don't think so.

We all have choices to make in life and those choices are made within the framework that is OUR life - comparing it to someone else's particularly to say that person A doesn't deserve to think twice about a decision but it is OK if Person B does is just plain wrong.

Let's ask a really silly question that uses similar logic here: Which parent hurts worse when a child dies? A rich parent or a poor parent? Answer - They both hurt the same as they are both PARENTS...

I used to tell people choosing a specialty not to pick obgyn unless you could not see yourself doing anything else. In other words, I thought I was in love with obgyn and nothing else would do. Twenty years later I still love it but it has not been a healthy love. Too much of me has gone to my job. I wish I had seen the plays and games of my children who are now grown and gone. Derm sounds like an excellent, useful career and I wish I had chosen it!

Dear Guest: I am happy you discovered you actually like Derm. What rubbed the wrong way about your post is you make it sound wrong for people to choose the specialties that do make them miss. I have to tell you I do Onc and have a very busy practice but I get to almost all bedtimes, school plays, etc. I also LOVE my job and CHOSE it specifically for the intellectual and emotional challenge. Comparing your internship to your career is apples and oranges. The irritation I feel is from the smugness you express that you want to do it for your kids. Ask KC about how much she loves her patient experiences or RH+ about some of her incredible deliveries when you have seen the 45th eczema of the day. Not every day for you will be the rare finding you like so much in NEJM. I would not trade for the world. Congrats on finishing your internship and good luck in your chosen specialty.

I agree with Oncologist Anon. The post is about how its wrong for you to work long hours. And because its wrong, you are choosing a life style specialty. But you are not in love with that specialty, and you are so magnificient in many other fields. So you make it sound that it was so emotionally hard for you to turn down demanding specialities (despite your greatness) and choose boring field (you make it sound like a sacrifice). Also this terribly boring field somehow became more appealing to you in the last year. You make it sound like a relief. This reminds me of my ex-colleague who was working 3 days a week (I am full time). She never covered for me when I needed to leave for emergent medical appointments even for an hour while I covered for her 4 months of maternity leave staying in the office till 11 pm at times. At her interveiw with our group she declared it is not acceptable for her to be full time, becasue she has better things to do for her kid (I had two toddlers myself at the time).So the climax of my interactions with her was when she produly announced that she DOES NOT have to work. But she is such a sacrificing hero, because she comes to the office a few days a week (no call no weekends). Everybody who know her just can't stop asking why in the world she is choosing to work, because you see, she DOES NOT have to. I knew she has not paid her educational debts yet. So, naturally I asked what makes her say she does not have to work. The answer: "Well, you know, my husbund is Dr.BigPayCheck" Somehow your post brings all these memories in mind.To other commenters "you can be rich and still complain" - sure, yes. We all are not poor. Just don't make your convinience choice sound like sacrifice.

I think all of us mothers in medicine struggle with the decisions we make in our careers-- this post is reflective of that. It goes without saying that we all have different experiences and motivators, but share a common thread--wanting to do what's best for our families and ourselves while fulfilling our desire to help others through medicine. There are no wrong ways to feel about that - not for others to decide for us, anyway.

Support, not tear down. That's what this site is about.

So to the writer of this post: I support you. Thank you for writing and reflecting. Having choices is a good thing. We have to make the one that is right for us, and it sounds like you did.

KC: I do not remember anyone "tearing down" FreshMD who works few days a week and is very dedicated to her family. Her posts are so emotionally rich and I personally admire people like her. I respect a lot of my women colleagues who work part time. Of course we support the guest writer's decision.Most of us raise families. She may just need to learn to be more humble about her choice and respectful of others who chose more difficult path. Thank you for starting this site. Its a great exchange of ideas.

We all of course support the author for her choice to do Derm whether it be from love of skin findings and science or because she feels relief from not having burdens of patient care or because she wants to be home with her kids. She should also acknowledge that every woman/mother in medicine makes choices that include being away from loved ones and medicine cannot support every woman doing dermatology for the hours. I think this is just as subversive as the Seibert article in NYT that demanded that all women work full time.

To those of you who see derm as "45 cases of eczema a day" - there are those for whom derm is extremely important. Like The Bearded One - over 30 years ago he was diagnosed with Psoriasis by a lowly Student Health Service dermatologist...on the basis of his symptoms mimicing those of the husband's. Following that, every doctor he saw said "No, you just have the world's dryest skin..". We switched laundry soap, bath soap, dish soap; double rinsed our laundry, got rid of scented ANYTHING in our home, used only pure cotton sheets (no blends), used only expensive hand and body lotions that had no gylcerin additives, etc. All the time he had skin cracks, chronic itching, blisters on weight bearing surfaces, and on and on.

FINALLY a dermatologist saw him who said, "Psoriasis - how did anybody miss this?" Well, they missed it because to them all skin problems other than acne and the bullous diseases and cancer were just "45 cases of eczema a day". They didn't care about SKIN and the chronic suffering of a person who had to "wear" it. Several new medications later, he is comfortable for the first time in many years.

@ Christie Critters: of course, dermatology is important. But admit that every specialty has the run of the mill cases and the majority of cases seen by the private practice dermatologist will not be the "psoriasis that everyone missed." No one is knocking the specialty. They are criticizing the tone of the writer saying that she could do anything but chose dermatology to see her kids, and then realized that hey she kind of liked it. If everyone chose their specialty based on her reasoning, there would be no one to diagnose the subtle arrhythmia or the allergic pneumonitis, or rare myeloproliferative disorder.We all make the choices that are best for us and our families but service is part of the job. I am sorry she felt the cost of her internship was so high and am glad she has the relief of light hours and liking what she does. I am also glad that someone else wanted to do the tougher hours.

To anonymous responding to Christie Critters: Yeah, there would be people who catch things that are not "run of the mill": The Son who says "Dad, just doesn't keep up with the kids the way he used to." The daughter that says, "Mom doesn't remember the Toll House cookie recipe that she made every week for years FROM MEMORY", The DENTIST who said "You're having trouble swallowing and just don't feel well? You shouldn't have dental treatment today. Let's call your MD" (and I use that MD referring to "doctor" term advisedly because DENTISTS ARE TOO DOCTORS - at least those worth their salt) -and and it turned out to be ALS. I found out from his wife a week later. I chose a lifestyle profession - dentistry - because I didn't want to deal with dying patients (and wanted to be with kids)and wound up (first year in practice) with a 3 year old with a terminal brain tumor, a terminal kidney failure in pain because her teeth were being "eaten alive" by the continuous vomiting, and the above person who "just didn't feel well" and guess what, I NOTICED and referred accordingly - to a doctor who said "So he has trouble swallowing and doesn't feel good - he's 67!"Well, he had ALS and I caught it - not that I knew it was ALS, but I knew that this was SOMETHING that I couldn't deal with; that I couldn't adequately treat his dental disorder until this was dealt with and that he had something significant that needed treatment.I chose a lifestyle profession, I didn't give up on doing my best for those in medical need. Just because I'm not a "real" doctor.

Get over it, people. Lots of information goes into a diagnosis - a plastic surgeon who treats congenital deformity (on his or her own time schedule) isn't any more worthy than a dermatologist or a dentist or a family pactitioner... Or anybody else for that matter. I will give a shout out for the thoracic surgeon who may treat my incipient MI...

im confused about so much here. mostly the comments, though. as an m2, I don't understand the nuances of specialty decisions and such, so maybe that's what I'm missing here. but I'm also confused about why people are mad that the original poster doesn't want to miss bedtimes? as if her desire to be very present as a mom somehow reflects negatively on those who aren't as present. I don't know much yet, but I think the point is that motherhood and medicine are both noble callings. every woman has to balance both callings in a way that brings her peace. I may have just missed some of the smugness bc im not at this point in my training yet. but I don't see why a woman admitting that she wants to be very present for her family would garner backlash from other moms.

@M2 I think that lifestyle has to play a part in specialty decisions. What is at issue is that the poster seems to state that was the exclusive reason she chose derm and later found she liked it. What many M2s do not realize is that the decisions continue even after the decision about specialty. You can regulate hours by doing part time, shared practice, academic practice. Choose what you love. You will be doing it a long time and training is very different than life as an attending. I am in a tough specialty and work full time, but I make it home and to special events too. AND, luckily I love what I do. Good luck in your choices!

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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